SEP-000359-2017 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development-Building&Codes (518)761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: SEP-000359-2017 Date Issued:
This is to certify that work requested to be done as shown by Permit Number SEP-000359-2017
has been completed.
Tax Map Number: 309.10-1-65
Location: 16 NEWCOMB ST
Owner: Rita Hay
Applicant: IBS Septic
This structure may be occupied as a: Residential Septic Alteration
By Order of Town Board
TOWN OF QUEENSSBBURYY
Issuance of this Certificate of Compliance DOES NOT relieve the
property owner of the responsibility for compliance with Site Plan,
Variance,or other issues and conditions as a result of approvals by the
Planning Board or Zoning Board of Appeals. Director of Building&Code Enforcement
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
OL Community Development-Building& Codes (518)761-8256
BUILDING PERMIT
Permit Number: SEP-000359-2017
Tax Map No: 309.10-1-65
Permission is hereby granted to: IBS Septic
For property located at: 16 NEWCOMBST
In the Town of Queensbury,to construct or place at the above location in accordance with application together
with plot plans and other information hereto filed and approved and in compliance with the NYS Uniform
Building'Codes and the Queensbury Zoning Ordinance
Type of Construction
Owner Name: Rita Hay Septic Disposal-Residential $0.00
Owner Address: 16 Newcomb ST Total Value $0.00
Queensbury,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
HIS Septic
2 WARREN ST
Glens Falls,NY 12801
Plans&Specifications
Residential Septic Alteration
$40.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday,June 22,2018
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensb before the exp}'(Jation dateOt,
)
Dated at the Town of ueensb {/ hur017
SIGNED BY: orthe Town of Queensbury.
Director of Building&Code Enforcement
SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
*co,.
742 Bay Road,Queensbury,NY 12804 L� 7
P:518-761-8256 www.gueensburv.net Permit#: x'_ 3�! ad
Tax Map ID#: 30g. /6"(_Q1 ((-- CC Permit Fee: $ ; Invoice#:
Project Location'. ��f �A(VVVI, I septic variance? Yes ,fes No
Primary Owner(s) t fC L� $ C1�,1�'s hex re–
Mailing Address Qbv
Phone & Email
Installer/Builder I hl IE G -
Mailing Address lowle W
Phone & Email A l
Engineer TOWN OF QUEENSBURY
COMMUNITY DEVELOPIVILl
Mailing Address
Phone & Email Pj
' vC • C�J(v�
Contact Person for Building&Code Compliance: Phone:
RESIDENCE INFORMATION:
Year Built #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder Yes No
1980 or older 4
Installed? (circle one)
Spa or Hot Tub Yes No
1981-1991 Installed? (circle one)
1992-Present
PARCEL INFORMATION:
Topography at Rolling _Steep Slope _%Slope
Soil Nature Sand _Loam _Clay _Other
Groundwater At w at depth?
Bedrock/Impervious material At Ahat depth?
Domestic Water Supply _Municipal —Well (if well, water supply from any septic system absorption is
Percolation Test Rate: per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYS rEM FOR NEW CONSTRUCTION:
Tank size e 1 1�) gallons(min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone Total length ft.; Each Trench ft.
Seepage Pit with#3 stone How many: : Size:
Alternative System Bed or other type:
Holding Tank System I Total required capacity? ;tank size ;#of tanks
NOTES:1.Alarm system &associated electrical work must be inspected by a Town approved electrical inspection
agency; 2.We will no longer allow systems to be covered until such time as an as-built plan is received and approved.
The installed system must match the septic layout on file—no exceptions.
Declaration:Any permit or approval granted which is based upon or is granted in reliance upon any material
representation or failure to make a material fact or circumstance known by or on behalf of an applicant,shall be void. I
have read the regulations and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage
Disposal Ordinance. r ��I
PRINT NAME4CEnforcement
DATE:
SIGNATURE: DATE:
Town of QueensRevised February 2017
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